tbuckley/cabot-search huggingface dataset:
Use of adjuvant bisphosphonate therapy in breast cancer by Indian oncologists: An implementation science study.
Authors: Sissmol Davis, Dr Serene Sara John, Dr Anjali Davichan, Aditya Santoki, Aju Mathew
Journal: Journal of Clinical Oncology (2023)

e13667 Background: Several clinical trials, expert consensus and guidelines have recommended the use of bisphosphonates (BP) in reducing the breast cancer recurrence risk in postmenopausal women. The 2019 St. Gallen Panel voted 83.7% in favour of the routine use of bisphosphonates in postmenopausal women. Similarly, the 2022 ASCO-Ontario Health guidelines for breast cancer supports the recommendation. However, the uptake of these recommendations in routine clinical practice is poorly studied. We aimed to investigate the use of adjuvant BP therapy by Indian oncologists (implementation science study). Methods: A cross sectional survey study design was used to investigate our research question. Physicians in India who treat patients with breast cancer were presented with a clinical vignette of a young woman with postmenopausal (induced) non-metastatic high risk hormone receptor-positive breast cancer. A snowball sampling strategy was employed to avoid sampling bias. Participants were requested to state their gender, primary qualification, practice setting, number of years of practice as an oncologist and proportion of patients with breast cancer in their practice. Instead of providing the option of BP therapy, we asked an open-ended question whether they would recommend any additional therapy other than surgery, radiation, chemotherapy and anti-estrogen therapy. We asked them to write in the name or class of drug if they would prescribe an additional therapy to the patient. Results: The survey was completed by 74 Oncologists. The response rate is unknown as a snowball sampling strategy was employed. Majority of the respondents were male (74%), were non-teaching private practitioners (42%), medical oncologists (62%) with up to 10 years of experience (65%), and breast cancer patients make up to 50% of their patients (84%). Most of the oncologists responded no to our question on additional therapy (76%). Of those who responded yes, only 8 suggested BP therapy (11%). Conclusions: Despite strong evidence and guidelines, adjuvant BP therapy in high-risk early breast cancer was only recommended by very few oncologists in our survey study. Steps to bridge this gap between academic research and clinical application is urgently warranted. Implementation of clinical guidelines has to be monitored routinely which may be facilitated by provider and patient surveys. This can also assist in identifying and addressing the concerns with newer recommendations.
Clinical pathways utilization and characteristics of non-adherence at Sidney Kimmel Cancer Center.
Authors: Sarah Houtmann, Steven Manobianco, Emily Hansinger, Adam F. Binder
Journal: Journal of Clinical Oncology (2023)

e13505 Background: Clinical pathways are utilized by many oncology practices with goal to deliver high quality, consistent care across health systems. In pathway tools, evidence-based treatments are recommended using the following hierarchy 1) efficacy, 2) adverse events, 3) cost. Previous research has shown that increasing adherence to pathways delivers evidenced based care at reduced cost. However, this comes at the expense of increased “clicks” and inefficiencies in workflow. We hypothesized that at a large academic center with subspecialty oncologists that lack of adherence to pathway utilization did not result in decrease adherence to evidence-based medicine. Methods: At our institution’s main academic hub, all breast, genitourinary (GU), and gastrointestinal (GI) chemotherapy encounters ordered from July 2020 through June 2021 were identified. A subset of these encounters, those ordered without use of Elsevier’s ClinPath, “pathway-independent,” were identified. Chart review was performed to identify clinical characteristics, ordering physicians, and line of treatment. Treatment choice was compared to ClinPath pathways to determine if treatment was “on-pathway” or “off-pathway.” Treatment was also compared to NCCN guidelines, to determine if aligns with standard of care. Results: 1,111 breast, GU, and GI total chemotherapy ordering encounters were identified. Only 103 (9.3%) were pathway-independent orders. 41 were hepatobiliary orders, which do not have a ClinPath pathway at our institution, leaving 62 pathway-independent orders despite a pathway available. 87% of the pathway-independent encounters were on-pathway, just not utilizing the ClinPath tool, and 91.9% align with standard of care. Only 8 of the 62 (12.9%) pathway-independent encounters were off-pathway. Of these 8 encounters, 4 (50%) were GI and 4 (50%) GU chemotherapy. 5 were 1 st line treatment, 2 were 2 nd line, and 1 was 3 rd line. 3 of 8 off-pathway encounters were in accordance with NCCN guidelines. There were justifications for 2 of the 8 off-pathway treatments: prohibitive hepatic dysfunction and patient preference to continue treatment ordered by outside institution. The remainder were by physician preference. Conclusions: At our academic institution, there was high utilization of ClinPath when ordering GI, GU, and breast chemotherapy, with 94.4% total encounters utilizing ClinPath. The vast majority of chemotherapy ordered at our center, even when ordered without ClinPath, aligns with standard of care. While the number of pathway-independent decisions was very small in this sample, it suggests that the clinical pathway tool may not influence clinical decision making as much as suggested in other studies, but likely adds administrative burden to physicians who practice in highly subspecialized areas.
Predicting treatment response for the safe non-operative management of patients with rectal cancer using an MRI-based deep-learning model.
Authors: Heather M. Selby, Charles Liu, Vipul Sheth, Sandy Napel, Todd Wagner, Arden M. Morris
Journal: Journal of Clinical Oncology (2023)

e15648 Background: Neoadjuvant chemoradiotherapy (CRT) followed by total mesorectal excision (TME) surgery has been the standard treatment for patients with locally advanced rectal cancer. Surgery, while effective in treating rectal cancer, can lead to significant long-term morbidity, such as bowel, urinary, and sexual dysfunction, and potential dependence on a colostomy for evacuation. A pathologic complete response (pCR) to neoadjuvant CRT suggests that TME surgery may not be necessary, as the tumor may have been effectively treated with CRT alone. However, the only definitive determination of pCR is based on a pathologic exam, which requires a surgical specimen. By comparing pre- and post-CRT images, clinical complete response (cCR) is a surrogate for pCR that does not require surgery. However, cCR is a poor proxy for pCR, with sensitivity and positive predictive values of 34.1% and 30.6% respectively 1 . Purpose: Our aim is to develop a multiparametric longitudinal MRI-based 3D deep-learning model to predict pCR in patients with locally advanced rectal cancer. Methods: We identified 360 patients with rectal cancer who had neoadjuvant CRT followed by surgical resection between January 2012 and December 2021 in an academic medical center. We have classified patients into two groups based on the presence or absence of pCR in their resected tumor specimen. We will train and validate a multiparametric longitudinal MRI-based 3D deep-learning model to predict pCR. Our model will use T1-weighted, T2-weighted with and without contrast, and/or diffusion-weighted MRIs before and after neoadjuvant CRT to predict pCR. Using multiparametric MRIs offers a comprehensive understanding of the tumor and surrounding tissue, and including longitudinal MRIs will provide valuable information on the impact of treatment. To assess the performance of the model, we will use receiver operating characteristic (ROC) analysis as well as positive and negative predictive values to evaluate its ability to predict pCR. Preliminary Results: Among 360 patients, 227 (63.1%) were male, 187 (51.9%) were Non-White, and the average age was 58.7 (SD of 13.3) years. The surgical pathology reports showed that 44 (12.2%) patients had achieved a pCR, while the visual assessment of post-CRT MRIs revealed that 49 (13.6%) had achieved a cCR. 1. Liu, C. et al. Predictive Value of Clinical Complete Response after Chemoradiation for Rectal Cancer. J. Am. Coll. Surg. 235, S51–S52 (2022).
Serial multiomic analysis in advanced breast cancer: A novel platform to inform therapeutic decisions.
Authors: Ben Kong, Jamie Keck, Brett Johnson, Jayne Stommel, Christina Zheng, Kiara Siex, Alexander Guimaraes, Christopher L. Corless, Zahi Ibrahim Mitri, Joe W. Gray, Gordon B. Mills, Raymond C. Bergan
Journal: Journal of Clinical Oncology (2023)

e13001 Background: We designed and implemented a platform wherein patients with metastatic treatment-refractory cancer would receive individually tailored treatment informed by multi-omic data and iteratively adapted in real-time. Here we describe the workflow of this platform and quantify operational characteristics for a metastatic breast cancer cohort. Methods: Participants with metastatic breast cancer progressing after standard-of-care therapy were enrolled. Sites demonstrating disease progression were targeted for biopsy. Resultant tissue was analyzed by a next-generation sequencing (NGS) solid tumor panel, whole exome sequencing, whole transcriptomic sequencing, multiplex protein analysis of a panel of cancer-relevant proteins and phosphoproteins, and focused immunohistochemistry (IHC) and fluorescence in-situ hybridization (FISH) analysis. Results: Between 1/1/2017 to 12/31/2021, 74 participants were consented and 55 were enrolled. Median age at enrollment was 54 years, most were ECOG 0-1, and received a median of 2 lines of therapy in the metastatic setting. There were 95 biopsies collected from 55 individual participants and analytics were successfully generated in 94% of the cases. At the provider’s request, an integrated clinical, molecular, and cancer biology tumor board (TB) was convened for 25 participants. A total of 21 participants received matched therapy based on clinical parameters coupled to a consideration of biologically informed therapeutic vulnerabilities and 6 had a PFS2/PFS1 &gt; 1.3. Twenty-one participants had a median of 2 repeat progression biopsies (range 2-5) and new alterations with potential therapeutic implications were identified. Repeat biopsies could have led to a new treatment in 11 of the participants, though only 3 received a therapy recommended by the tumor board owing to either rapid disease progression, clinical deterioration, or lack of access to drug. Conclusions: We demonstrated the practical feasibility and initial operating characteristics of a platform designed to comprehensively understand and integrate the clinical and molecular characteristics of a cohort with metastatic progressive breast cancer as they evolve on therapy and to use this information to deliver iteratively tailored therapy in real time. Further, clinical responses were observed in a subset of participants. These findings suggest an opportunity to incorporate this platform earlier in a disease course or to design adaptive clinical trials with access to therapies aimed at targeting new biological alteration.
Characterization of patients with recurrent breast cancer submitted to neoadjuvant therapy in a Brazilian cancer center.
Authors: Guilherme Rossato de Almeida, Monique Celeste Tavares, Solange Moraes Sanches, Marcelle Goldner Cesca, Luciana de Moura Leite, Vladmir Cordeiro Lima, Fernando Augusto Batista Campos
Journal: Journal of Clinical Oncology (2023)

e13013 Background: Breast cancer patients submitted to neoadjuvant therapy have clinical-pathological factors that can correlate with favorable outcomes, such as pathologic complete response (pCR). However, patients who achieve pCR may develop recurrence due to other identifiable risk factors, and some molecular subtypes lack a prognostic marker such as pCR, depending on other factors to determine the risk of recurrence. Objective: Analyse clinical-pathological data from patients with recurrent breast cancer who received neoadjuvant therapy, and identify possible risk factors in this population. Methods: This is an observational, descriptive, retrospective study of patients with recurrent breast cancer, submitted to neoadjuvant therapy between January 2007 and December 2018, at the AC Camargo Cancer Center; São Paulo, Brazil. Of the 1145 patients treated with neoadjuvant therapy, we evaluated 304 who recurred, and crossed data with 841 patients that didn't present recurrence. Results: We analysed 304 patients (26.6%), 60.1% pre-menopause, 6.5% with BRCA1/2 gene mutation, 85.9% had invasive ductal carcinoma (IDC), 53.8% were histologic grade (HG) III, and 84.2% had KI67 &gt;20%. Clinical stage was 44.7% cT4, 28.3% cT3, 25.7% cT2 and 1.3% cT1, while 13.3% were cN3, 21.1% cN2, 43.8% cN1 and 21.7% cN0. Grouped clinical stage was 74.4% III, 25% II and 0.7% I. Molecular subtypes were 52.4% hormone receptor positive/HER2 negative (HR+/HER2-), 12.2% HR+/HER2+, 6.9% HR-/HER2+ and 28.6% HR-/HER2-. Regarding neoadjuvant chemotherapy, 92% received anthracycline and taxane, 23% dose-dense, 17.4% received trastuzumab with or without pertuzumab, and 20% of ER-/HER2- received carboplatin. Chemotherapy interruption occurred in 13.2% of patients, and 31.1% interrupted anti-HER2 therapy. Surgery was 82.9% mastectomy, 77% axillary dissection and 16.4% breast-conserving surgery. Residual Cancer Burden (RCB) score was 13.1% RCB 0, 5.8% RCB I, 35.3% RCBII and 45.8% RCB III. Ninety percent received adjuvant radiotherapy, 9.2% adjuvant capecitabine and 45% of HR+ adjuvant tamoxifen. We observed recurrence association with HG III ( p = 0,001), Ki67 &gt;20% ( p = 0,001), clinical stage III ( p &lt; 0,001), cT4 and cN2/3 ( p &lt; 0,001), RBC &gt; II/III ( p = 0,001), molecular subtypes HR+/HER2- and HR-/HER2- ( p = 0,042), interruption of neoadjuvant therapy ( p = 0,002) and anti-HER2 therapy ( p = 0,012), and use of adjuvant tamoxifen ( p &lt; 0,001). Adjuvant capecitabin and radiotherapy had no correlation with the outcome. Conclusions: Recurrence was associated with intrinsic factors, such as HG III, Ki67&gt;20%, cT4, cN3/4 and molecular subtype, as well as RCB &gt; II/III, treatment interruption and choice of adjuvant hormonal therapy, pointing out possible risk factors in our population.
Survival outcomes and clinicopathological factors analysis of breast cancer patients. A single-institution cohort from 2012 to 2020 in a Mexican population.
Authors: Rocio Grajales, Alicia Gutierrez, Christian Pichardo, Marcos Gutierrez, Abdel Karim Dip Borunda
Journal: Journal of Clinical Oncology (2023)

e13104 Background: In Mexico, The Instituto Mexicano del Seguro Social (IMSS) is a tripartite contribution which provides care to more than 74 million beneficiaries, which represents more than 50% of the general population of the country. Although Mexican breast cancer statistics have been reported, it is imperative to know the updated statistics on the epidemiology in our Institution. The aim of this study is to describe the survival outcomes and the clinical-pathological characteristics of patients with breast cancer. Methods: Records of breast cancer patients treated at the Oncology Hospital from Centro Medico Nacional Siglo XXI of IMSS, from January 2012 to December 2020 were included. We analyzed clinical and demographic characteristics of the population, as well as survival outcomes at 5-years. Results: A cohort of 5,264 patients was included. Median follow up was 54.9 months. Forty-three percent (n = 2,274) were diagnosed in early-stage breast cancer (I–IIA), 43.1% (n = 2,269) in stages IIB-III, and 7% (n = 383) in stage IV. The most common immunophenotype was hormone receptor (HR) positive, HER2-negative (70.8%, n = 3,726). HER2-positive represents 19.3% (n = 1011), among HR-positive were 12.4% (n = 650) and HR-negative, 6.9% (n = 361). 527 patients (10.1%) were triple negative. At 5-years, disease-free survival was 74.9% (95% CI, 73.5 to 76.3) and overall survival was 90.4% (95% CI, 89.4 to 91.3). High histologic grade (HR 1.51; 95% CI, 1.33 to 1.7; p &lt; 0.001) and lymphovascular invasion (HR 1.84; 95% CI, 1.62 to 2.1; p &lt; 0.001) were associated with higher risk of recurrence. Adjuvant chemotherapy was significantly associated to a 42% reduction in the risk of recurrence, HR 0.58 (95% CI, 0.49 to 0.69; p &lt; 0.0001), and 54% in the risk of death, HR 0.46 (95% CI, 0.33 to 0.63; p &lt; 0.0001) in stage III. Lobular histology was also associated with worse survival, HR 1.41 (95% CI, 1.069 to 1.859; p = 0.015). Conclusions: An update of breast cancer Mexican patients treated at IMSS is presented. We highlight the impact of adjuvant treatment and pathological risk factors for recurrence and death. This work can contribute to evaluate areas for improvement in management and outcomes in our population.
Current trends in oncology-related utilization of digital health (telemedicine, RPM, and asynchronous messaging).
Authors: Cindy Revol, Austin Miller, Sanjula Jain, Allison H. Oakes
Journal: Journal of Clinical Oncology (2023)

e13688 Background: It is well established that digital health (particularly telehealth) utilization increased in response to the COVID-19 pandemic; however, the extent to which digital health is used in oncology care is unknown. Conceptually, telehealth and other digital health solutions may alleviate some of the emotional, financial, and physical burdens associated with receiving oncology care. The objective of this study was to examine trends in the utilization of digital health (telehealth, remote patient monitoring (RPM), and asynchronous messaging (AM)) among cancer patients and the demographics of those patients relative to digital health and oncology patients writ large. Methods: We used the Trilliant Health national all-payer claims database to analyze digital health interactions for both oncology and non-oncology patients from Jan 2020 - Jun 2022. We defined a digital health visit as any visit with a procedure code for telehealth, RPM, or AM. An oncology care visit (digital or in-person) was defined as any visit with a primary diagnosis of cancer. An oncology digital health visit was defined as a visit with one of the digital health procedure codes coupled with a primary diagnosis of cancer. Results: Digital health represented 3.19% of total oncology care volume, a majority of which was telehealth (3.18%). Among all telehealth visits, 0.9% of visits were for oncology-related care. Additionally, a majority (72.8%) of these oncology-related telehealth visits were for E&amp;M encounters related to ongoing cancer care. By payer type, telehealth visits were more common among commercially insured patients (56.1%) compared to commercially insured patients’ share of all oncology care (39.8%). While overall telehealth utilization is disproportionately female (62.2%), women comprised 51.2% of all oncology care volume and 52.5% of all oncology-related telehealth volume. While the 65+ population accounts for just 19.3% of all telehealth volume, they are responsible for 61.1% of telehealth oncology-related volume–more closely resembling that age group’s 73.5% share of total oncology care volume. Oncology care represented 0.2% and 0.5% of total RPM and AM volume, respectively. Conclusions: Oncology digital health visits remain a very small portion of overall digital health utilization and total oncology care. Prior research found that the share of younger patients seeing oncology providers is increasing over time, signaling worsening patient acuity. Given the demand for digital health overall skews younger, it is likely that demand for more virtual cancer care services will increase. While research suggests digital health yields cost savings, more needs to be understood about the quality implications of virtual versus in-person visits. While virtual care increases access to those with time and travel constraints, providers need to ensure equal access to these services for all patients.
Therapeutic strategies for metaplastic breast cancer: A clinicopathologic analysis of a single institution cohort.
Authors: Hemali Batra-Sharma, Kay T Yeung, Rebecca Arielle Shatsky
Journal: Journal of Clinical Oncology (2023)

e13128 Background: Metaplastic breast cancer (MpBC) is a rare, aggressive, and histologically diverse subtype, which is associated with worse survival outcomes than other triple-negative breast cancers. Methods: This study is a single-institution retrospective analysis of 30 patients with MpBC, focused on response to therapies in the context of histologic subtype, molecular alterations, and PD-L1 expression. Patients with MpBC who received treatment at our institution consented to share clinical information with a research biorepository. Clinicopathologic and next generation sequencing (NGS) data were obtained from patients’ electronic health records. The primary outcomes are overall survival (OS) and event-free survival (EFS), and the secondary outcomes are responses to neoadjuvant therapy, tumor growth on taxane and/or anthracycline, and responses to systemic therapy in the relapsed/metastatic setting. Results: Among the 30 MpBC patients, the median age at diagnosis was 47.5 years. 86.7% were diagnosed with early-stage disease, 36.7% with squamous cell MpBC, 93.3% with triple-negative disease, and 30% with HER2-low disease. Of the patients diagnosed with early-stage disease, 88.5% received neoadjuvant systemic therapy, 96.2% underwent breast surgery, 92.3% received definitive/adjuvant radiation, and 76.9% received adjuvant systemic therapy. 61.5% of patients with localized disease experienced local and/or distant relapse. Median EFS was 14.0 months (95% CI, 10 to 20 months). Median OS was 26.5 months (95% CI, 20 to 32 months). There was no clearly superior neoadjuvant regimen based on MpBC subtype, but more patients with squamous MpBC experienced tumor growth on taxane-containing therapy compared to those with growth on anthracycline-containing regimens. In the relapsed/metastatic setting, patients with squamous cell MpBC and somatic mutations in the PI3K/Akt/mTOR pathway had prolonged partial responses to combination treatment with an anthracycline, mTOR inhibitor, and VEGF inhibitor. Median treatment duration with sacituzumab govitecan in the 1 st or 2 nd line metastatic setting was 1.5 months (95% CI, 1 to 4 months) before disease progression. Low tumor mutational burden was seen across all MpBC subtypes (median 2.1, 95% CI 1.6-4.0). 75% of the cases were PD-L1 positive by Immune Cell expression. There was no clear association between PD-L1 expression and response to immunotherapy-containing treatments in the neoadjuvant or relapsed/metastatic setting. Conclusions: Our findings on the presentation of MpBC correlate with other clinicopathologic studies. For squamous MpBC, we noted trends on the utility of anthracycline-containing regimens. Chemoimmunotherapy and antibody-drug conjugates have changed management of triple-negative and HER2-low breast cancer, but more prospective data are needed to determine the optimal therapeutic strategies for MpBC.